Abstract Background/Aims Getting It Right First Time (GIRFT) is a national programme that aims to improve the care of patients through in-depth review of services. The programme undertakes clinically led reviews of specialties, combining data analysis with professional knowledge of senior clinicians to examine how things are currently being done and how they could be improved. The programme is backed by the Royal Colleges and professional associations. In 2022, Bradford Teaching Hospitals had their rheumatology GIRFT review. Recommendations were made around coding and documentation in keeping with the national GIRFT report. We carried out an audit looking at the coding of intramuscular injections and intra-articular injections in the outpatient setting, and reviewed documentation of counselling for these procedures. This led to a review of ‘Payment By Results’ tariff data using Office of Population Censuses and Surveys (OPCS) codes to evaluate the financial benefits to our department. Accurate coding of procedures in outpatient settings also supports the Elective Recovery Fund (ERF) programme. This audit aims to evaluate current practice in the coding, counselling, and documentation of intra-articular and intramuscular steroid injections within the outpatient rheumatology service, and to implement improvements in line with GIRFT recommendations. Methods A retrospective review of clinic notes during the month of May 2025 was carried out. All outpatient appointments were reviewed. 50 steroid injections were identified that were administered either intramuscularly or intra-articularly. Data collected included the correct coding and documentation of specific counselling for side effects. Findings were presented at the local clinical governance meeting. Interventions included staff education and discussion with the business intelligence team to streamline correct coding processes. A re-audit is planned six months after the initial review. Results The data identified a discrepancy in procedure code W90.3 (therapeutic substance into a joint, attracting a different tariff if assigned to pain management or rheumatology), which has been escalated to NHSE for consideration. Depending on what tariff is assigned to the procedure code W90.3, the data showed that a lack of correct coding in 84% of cases amounted to an estimated loss of £2,496 to £13,564 per month to the department. Documentation of counselling varied between clinicians. Some clinicians adopted a broad statement to cover the counselling process, while others stated specific risks. Conclusion This audit demonstrated the clinical and financial importance of accurate coding and standardised documentation for steroid injections. Improved coding supports local and national objectives, including GIRFT and ERF objectives in improving elective recovery through capturing rheumatology activity accurately. Variation in counselling documentation highlights the need for national guidance. The department plans to introduce a standardised electronic template and patient information leaflet to enhance documentation, quality improvement, and information governance. Disclosure P. Manu: None. K. Nadesalingam: None.
Manu et al. (Wed,) studied this question.